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Common Forms

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Questions




If you have questions or need assistance, call our Provider Relations Department at:

1-714-246-8600

Monday through Friday from 8 a.m. to 4 p.m. Pacific Time

Find Common Forms

We want to make it easy for you to find the forms you need. If you don't see the form you are looking for, or if you aren't sure which one you need, please call our Provider Relations Department at the number on the right side of the screen. We are here to help you.

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1500 Health Insurance Claims Form for 2014PDF File Indicator Image

A

Adult Transplant Notification Request FormPDF File Indicator Image

Annual OneCare (HMO SNP) Health Risk AssessmentPDF File Indicator Image

Appeals and Grievance Form - OneCare (HMO SNP)PDF File Indicator Image

Appointment of Representative FormPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) - EnglishPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) - SpanishPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) - VietnamesePDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) - FarsiPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) - KoreanPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend - EnglishPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend Involved in Care - SpanishPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend Involved in Care - VietnamesePDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend Involved in Care - FarsiPDF File Indicator Image

Authorization for Use or Disclosure of Protected Health Information (PHI) to Family Member or Friend Involved in Care - KoreanPDF File Indicator Image

Authorization Request Form (ARF)PDF File Indicator Image

Authorization Request Form (ARF) for Community-Based Adult Services (CBAS)PDF File Indicator Image

Authorization Request Form (ARF) for OneCare ConnectPDF File Indicator Image

B

Benefit Inquiry for Community-Based Adult Services (CBAS)PDF File Indicator Image

C

CBAS Incident Reporting FormPDF File Indicator Image

CBAS Member Discharge Plan and ReasonPDF File Indicator Image

Childhood Obesity / Health Education Request FormPDF File Indicator Image

Code of ConductPDF File Indicator Image

Customized Wheelchair Evaluation RequestPDF File Indicator Image

D

Diabetes Action Plan - EnglishPDF File Indicator Image

Diabetes Action Plan - SpanishPDF File Indicator Image

Diabetes Action Plan - VietnamesePDF File Indicator Image

E

End Stage Renal Disease Medical Evidence Report Medicare Entitlement and/or Patient Registration

H

Health Education / Disease Management Referral FormPDF File Indicator Image

I

IHSS Communication FormPDF File Indicator Image

Individual Request for Access to Protected Health Information (PHI) - EnglishPDF File Indicator Image

Individual Request for Access to Protected Health Information (PHI) - SpanishPDF File Indicator Image

Individual Request for Access to Protected Health Information (PHI) - VietnamesePDF File Indicator Image

Individual Request for Access to Protected Health Information (PHI) - FarsiPDF File Indicator Image

Individual Request for Access to Protected Health Information (PHI) - KoreanPDF File Indicator Image

L

Long-Term Care Treatment in Place Notification FormPDF File Indicator Image

M

Member Complaint Form - Medi-CalPDF File Indicator Image

Member Complaint Form - Medi-Cal - FarsiPDF File Indicator Image

Member Complaint Form - Medi-Cal - KoreanPDF File Indicator Image

Member Complaint Form - Medi-Cal - SpanishPDF File Indicator Image

Member Complaint Form - Medi-Cal - VietnamesePDF File Indicator Image

Member Request to Amend Protected Health Information (PHI) - EnglishPDF File Indicator Image

Member Request to Amend Protected Health Information (PHI) - SpanishPDF File Indicator Image

Member Request to Amend Protected Health Information PHI - VietnamesePDF File Indicator Image

Member Request to Amend Protected Health Information PHI - FarsiPDF File Indicator Image

Member Request to Amend Protected Health Information PHI - KoreanPDF File Indicator Image

Mental Health Level of Care Screening ToolPDF File Indicator Image

Multipurpose Senior Services Program (MSSP) - ReferralPDF File Indicator Image

MSSP LTC/SNF Incident Reporting FormPDF File Indicator Image

N

Non-Emergency Medical Transportation (NEMT) Authorization RequestPDF File Indicator Image

O

OC.CYS Inpatient Notification and Coordination FormPDF File Indicator Image

OC.CYS Mental Status Screening FormPDF File Indicator Image

P

Pregnancy Notification ReportPDF File Indicator Image

Provider Dispute Resolution Request FormPDF File Indicator Image

Provider Complaint Resolution Form - Level IIPDF File Indicator Image

R

Request for Accounting of Disclosures - EnglishPDF File Indicator Image

Request for Accounting of Disclosures - SpanishPDF File Indicator Image

Request for Accounting of Disclosures - VietnamesePDF File Indicator Image

Request for Accounting of Disclosures - FarsiPDF File Indicator Image

Request for Accounting of Disclosures - KoreanPDF File Indicator Image

Request for Letter of AgreementPDF File Indicator Image

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - EnglishPDF File Indicator Image

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - SpanishPDF File Indicator Image

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - VietnamesePDF File Indicator Image

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - FarsiPDF File Indicator Image

Request for Restriction on Use or Disclosure of Protected Health Information (PHI) - KoreanPDF File Indicator Image

Restriction on Manner/Method of Confidential Communication - EnglishPDF File Indicator Image

Restriction on Manner/Method of Confidential Communication - SpanishPDF File Indicator Image

Restriction on Manner/Method of Confidential Communication - VietnamesePDF File Indicator Image

Restriction on Manner/Method of Confidential Communication - FarsiPDF File Indicator Image

Restriction on Manner/Method of Confidential Communication - KoreanPDF File Indicator Image

Retro Authorization Request for Acute Inpatient CarePDF File Indicator Image

S

State Fair Hearing FormPDF File Indicator Image

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - EnglishPDF File Indicator Image

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - SpanishPDF File Indicator Image

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - VietnamesePDF File Indicator Image

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - FarsiPDF File Indicator Image

Statement of Disagreement Request to Include Amendment Request and Denial with Future Disclosures - KoreanPDF File Indicator Image

Suspected Fraud or Abuse Referral Form - EnglishPDF File Indicator Image

Suspected Fraud or Abuse Referral Form - SpanishPDF File Indicator Image

Suspected Fraud or Abuse Referral Form - VietnamesePDF File Indicator Image

Suspected Fraud or Abuse Referral Form - FarsiPDF File Indicator Image

Suspected Fraud or Abuse Referral Form - KoreanPDF File Indicator Image

UB04 Claims FormPDF File Indicator Image

W

Waiver of Liability Statement - OneCare (HMO SNP)PDF File Indicator Image

Wheelchair Clinical QuestionnairePDF File Indicator Image

Wheelchair Repairs Authorization RequestPDF File Indicator Image

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